Provider Demographics
NPI:1083078414
Name:GREEN, KAYCEE (ATC)
Entity Type:Individual
Prefix:
First Name:KAYCEE
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4057 ROLLINGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHSIDE
Mailing Address - State:AL
Mailing Address - Zip Code:35907-0964
Mailing Address - Country:US
Mailing Address - Phone:256-504-5062
Mailing Address - Fax:
Practice Address - Street 1:6002 PROFESSIONAL PKWY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-5600
Practice Address - Country:US
Practice Address - Phone:770-949-8558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0029142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer